Steven J. Taylor, Alice Brumby, eds. Healthy Minds in the Twentieth Century: In and Beyond the Asylum. Cham: Palgrave Macmillan, 2019. 274 pp. $31.00 (cloth), ISBN 978-3-030-27274-6.
Reviewed by Pamela L. Dale (University of Exeter)
Published on H-Disability (October, 2020)
Commissioned by Iain C. Hutchison (University of Glasgow)
This is an ambitious collection of essays. The introductory chapter is quite short, but it offers a useful survey of the current state of the historiography and then sets out a bold agenda for future research. Oddly, the editors say nothing about what brought the different contributors together but, even without mention of a conference or seminar series that inspired the project, there is a strong sense of coherence. Each chapter is unique, and important in terms of content and approach. Yet there is also a real sense of shared endeavor. The case studies speak to each other as well as engaging with a common set of core issues and texts. None of the authors flinch from addressing the ethical and moral dilemmas highlighted by the editors and illuminated by their own work.
A focus on “healthy minds” provides plenty of thought-provoking material and one of the strengths of the book is allowing this concept to have multiple and highly subjective meanings in which context is everything. This approach is clearly set out in the introduction and has been successfully adopted by all of the contributors. An interest in “healthy minds” chimes with twenty-first-century preoccupations with mental health and emotional well-being. However, the editors also reveal how a much earlier interest in “healthy minds” was associated, not with self-realization and personal fulfillment, but with ideas about social efficiency. The contributors then demonstrate that the flip side of a concern to actively promote mental health (constructed in terms of medical, legal, educational, social, and cultural norms) was a policy of identifying and then segregating (even sterilizing) those deemed to have “unhealthy” minds. Such thinking, and practices, were by no means confined to the asylum era, and some of the later chapters disturbingly reveal how little has changed in terms of the marginalization and stigmatization of those living with serious mental health conditions and/or learning disabilities.
Throughout the book, ideas about “healthy” and “unhealthy” minds are shown to be constructed by a variety of actors in any number of spaces both real and imagined. This is interesting work and builds a sense of inclusiveness. No one view of mental health (or ill-health) is privileged and instead doctors (not just psychiatrists), healthcare workers, social workers, and educationalists in the broadest sense are allowed to contribute. Most importantly, the opinions, experiences, needs, and preferences of lay people, especially service-users and their families, are not just considered, but foregrounded. The resulting analysis is sophisticated but, in some ways, problematic for the reader. There are no heroes and no villains in these accounts, just a large number of people struggling with incredibly difficult issues that may actually have no solution when thinking about them in the past, present, or future.
For many years, better resourcing was seen as the answer to various crises in mental healthcare. While some commentators agree that the potential of the asylum, insofar as it ever existed, had been exhausted by the end of the nineteenth century, many actors continued to argue that investment in early- and mid-twentieth-century mental hospitals was essential and would reap benefits for society as a whole as well as those more immediately affected by these services. The movement towards deinstitutionalization fatally undermined that idea, but the chronic, and in many ways deliberate, under-resourcing of community care projects meant their failures tended to be discussed in those terms. This left unexplored the perhaps more fundamental question of what good community care could and should look like. Contributors to Healthy Minds provide many useful talking points. A number of alternative voices provide insider and outsider perspectives—although only limited attention is given to the general public, whose support for mental health reforms seems a prerequisite for necessary improvements.
The case studies all make a strong case for recognizing the specific needs of different groups of people who might be in contact with various mental health services. As a reader, one cannot help but empathize with people’s desire for recognition and support without having to surrender their identity, autonomy, or independence. Indeed, such is the prevalence of mental health concerns that it would be a very arrogant reader who thought these issues had no applicability to their own lives. However, when approached as a taxpayer or potential charitable donor the same reader might easily feel overwhelmed by the scale of the apparent level of need, or irritated by the special pleading made by all the different groups who seem happy to compete for attention and resources rather than discussing systemic reforms or the full implications of everything that they are requesting. Jan Walmsley goes as far as to suggest that changing attitudes toward people living with learning disabilities may well require a fundamental reassessment of what it means to be human. To date there seems limited interest in such a reimagining, but I share her frustration with the minimal achievements of supposedly socially inclusive policies over many decades.
Contributors to Healthy Minds have a range of disciplinary backgrounds, but the editors have conceived the project as a response to Peter Bartlett and David Wright’s classic text Outside the Walls of the Asylum.[1] This orientates the work toward the concerns of social historians of medicine. Several years ago, the subfield that might be termed the social history of madness was flourishing and, after a period of fewer publications, it is good to see a strong body of new work, of which Healthy Minds is only a part, emerging. This research is inclusive in terms of participation and topics addressed, whereas recent literature written by and for healthcare practitioners can feel less accessible. In particular, mental health nurses have been unhelpfully territorial when thinking about the past as well as the present and the future of their profession. Healthy Minds seeks not just to broaden debate but shows how different service-providers and service-users have benefited, or not, from shared ideas and experiences. For this reader, it is wrong to write physical, sensory, and learning disabilities out of accounts of mental healthcare and vice versa.
Anxieties about shared stigma make some researchers reluctant to associate disability and mental health, but this is not addressed by ignoring connections and areas of mutual concern. Indeed, one of the strengths of Healthy Minds is its determination to open new fields of inquiry by including conditions that have previously been relatively neglected because they sit uneasily between different specialisms. The three chapters exploring epilepsy and aspects of autism demonstrate the value of taking a holistic approach that evaluates rather than ignores the contribution of, for example, neurology as well as psychiatry. Chapters 7 and 8 draw on ideas from the neurodiversity movement, which challenges the “disablement of difference” and embraces “social health activism” (p. 170). The really interesting descriptions of an online community of young adults crafting and celebrating their identity places these concerns in the very recent past, but Erika Dyck and Ginny Russell, as well Michelle O’Reilly, Jessica Nina Lister, and Nikki Kiyimba, all locate these developments in a much longer history that captures changing medical discourses and diagnoses as well as responses from service-users, both willing and unwilling. There is a sense of increasingly rapid change and heightened tensions.
Rachel Hewitt explicitly addresses the way epilepsy has occupied “an awkward position within the disability studies movement” (p. 53). She goes on to explain how living with, and often being forced to conceal, a hidden disability like epilepsy had many parallels with people’s experience of managing long-term mental illnesses. While the historiography can present a view of triumphant progress toward greater scientific understanding of the condition, Hewitt points out that the day-to-day problems of living with epilepsy were not simply resolved. Her work explores how changing services for people with epilepsy both shaped and responded to new thinking about the condition.
The resulting chapter concentrates on institutional provision for younger people in the first half of the twentieth century, but its methodology and conclusions have potentially far wider application. It certainly felt very relevant when I was listening to a recent radio discussion about the possible use of medicinal cannabis in cases of uncontrolled childhood epilepsy. There was also a more personal connection. Two people I know have recently disclosed that they have epilepsy, in distressing circumstances not of their own choosing. Both these middle-aged professional men, one a teacher, the other a civil servant, had successfully managed their condition for decades but suddenly started having unpredictable seizures. Interestingly, they both attributed this to enforced medication changes, but also linked the return of their epilepsy to periods of acute stress at home and at work. The teacher has divorced and is exploring the option of early retirement.
Education and employment were, and are, among key battlegrounds for people living with disabilities and/or mental health problems. Both can be sites of inclusion as well as exclusion. In chapter 4, Steven Taylor concentrates on the evolution of special education and, like Hewitt, takes an approach that embraces both “abstract conceptualisations of ‘healthy’ minds” and “more tangible lived experiences” (p. 73). My interest in special education in the era of the Mental Deficiency Acts dates back to PhD research more than twenty years ago, but I still found Taylor’s review of the historiography, as well as the important Birmingham case study, novel and interesting. It also serves as a cautionary tale. In the twenty-first century, there are all kinds of self-proclaimed experts with pet projects to promote. The farcical end of Sandwell Hall School, so well described by Taylor, shows how “personalities” can easily detract from the charitable causes they were meant to be promoting. In the Sandwell Hall School example, the motivations of leading figures, combining personal gain and suspect eugenic ideologies, were far from benign, but their malign contribution alas proved hugely influential at a national as well as local level.
Yet if Sandwell Hall and similar institutions were too powerfully promoted, Remploy was an organization that was perhaps overly modest about its aims and achievements. Andy Holroyde gives a sensitive and comprehensive account of Remploy’s work c. 1945-81. He makes the important point that Remploy’s involvement with workers experiencing mental health problems was a long-term project that did not simply start with the 1959 Mental Health Act. However, acceptance at a theoretical as well as practical level within the organization had to be constantly renegotiated—with Remploy needing to position itself as an increasingly commercial enterprise as well as respond to changing ideas about healthy and unhealthy minds. Holroyde shows how the participation of mentally disabled as well as mentally ill people raised many questions, not least because organizational requirements allowed for few personal idiosyncrasies. As mentally ill and disabled people became an increasingly important part of the Remploy workforce, this created long-term uncertainties, although the intensification of attacks on Remploy after 1979 were not only about hostility to that organization and its model of sheltered employment.
Holroyde’s work takes us into new territories, as the problems of community care are often explained in terms of shortages of accommodation rather than shortages of employment. One area of concern is a lack of hospital beds, but access to supported, shared, and independent accommodation that might aid rehabilitation or prevent admission has also been highly problematic. Many of these difficulties would be eased, if not resolved, by policies that promoted employment opportunities for service-users or provided a more generous benefits system for those unable to work. Historically, a current or perceived future inability to be economically self-supporting was often a trigger for intrusive assessments and institutional segregation.
These points are interestingly explored in chapters 3-6. Holroyde’s chapter then examines efforts to boost and sustain employability in the third quarter of the twentieth century before chapters 7-9 capture diverging experiences in the more recent past. The families connected with the National Schizophrenia Fellowship would have been responsible for the finances as well as care of their relatives. This could be just one more burden since it is unlikely that any of the seriously ill service-users were in regular or well-paid employment. Those engaging with late twentieth-century debates about autism were in a different position, although divisions within this group led many to overly optimistic conclusions. Some people with conditions on the autism spectrum are nonverbal and incredibly vulnerable in all care settings. However, other people diagnosed, and self-identifying, as autistic are able to enjoy successful careers and the personal and social independence that flows from being self-supporting.
Their understandable self-confidence, and interest in exploring their personal experiences within potentially stigmatizing disease labels, undoubtedly—although, arguably, constructively—challenges professional power. It has also problematized the role of parents who start on a diagnostic journey because of concerns they or others have about their child. The child now labeled as an autistic child may take a very different view of these supposedly problem behaviors, which they see as intrinsic to themselves.
In some important ways the vibrant online communities created by young autistic people, and in a different sense their parents who also seek information and support on the internet, both echo and develop earlier survivor networks and support groups. These issues are fully explored in chapter 8, which makes a very interesting counterpoint to chapter 7’s discussion that centers on changing medical/scientific thinking and the evolution of diagnostic categories. In a different way, these points are explored in Alice Brumby’s chapter on the National Schizophrenia Fellowship (NSF). Various charitable organizations had emerged to protect and promote the welfare of mental health patients, but in the 1960s and 1970s there was a perceived crisis in the sector with upheavals caused by the deinstitutionalization movement, which encouraged a new approach.
The NSF was once a groundbreaking pioneer, but in recent years it and other, similar groups have had to adapt to deal with criticism suggesting they had become old-fashioned and even patronizing toward the people they were meant to represent. Brumby takes a different view of the challenges facing the NSF throughout its history, and by keeping family caregivers at the center of her analysis shows the timelessness of their concerns and their need for support. It is not ironic when she demonstrates that the main strength of the NSF may well have been the mental health support it offered to family members dealing with severe mental illness on a daily basis. Organizations might come and go, but it seems the problems of caring are as endless as they are unlimited.
The demands that serious mental illness place on professional carers, as well as families and communities, has been an important theme in many studies of Victorian and Edwardian asylums. It would be good to see this work extended, but there is only limited scope to do so. The editors of Healthy Minds usefully explore the barriers that prevent access to the necessary archival sources in their introduction, but offer no clear remedy. I share their frustration that when dealing with periods after the long nineteenth century, projects are forced to develop alternative foci concentrating on available records. This is fueled by a personal concern that the cloak of secrecy placed over much of the relevant data has far more to do with protecting institutional reputations than preserving patient confidentiality.
While the editors do not fully develop the argument, the thematic approach adopted in Healthy Minds is an effective way of building understanding of models of care across several time periods, some having received more attention from historians than others. Alice Mauger locates her study of alcoholism and medicine in Ireland between 1890 and 1921. This could be just another asylum study from the long nineteenth century, but in many important ways it is not. In an Irish context, Mauger presents the quest for sobriety as a key component of the journey toward national as well as personal self-government. She reveals how medical interests aligned with, and were promoted by, this project. However, she also reveals the way some doctors, fearing overwhelming and inappropriate demands for treatments from patients and their families, sought to limit medical involvement in this field.
Making sense of the mind, both healthy and unhealthy, both individual and collective, has been an important twentieth-century project that has not just involved medicine, science, and policymakers. There has been an important cultural dimension to the exploration and understanding of the mind and the underlying question of what it means to be human. In chapter 11, Rob Mayo develops powerful insights from both the creation and reception of ideas that originate in quite an obscure strand of the science fiction genre but have recently entered the mainstream in the blockbuster movie Inception (2010). He explains the film’s success in terms of the audience’s desire to “see” the mind and understand its relation to their physical world. There is no doubt that the arts, and perhaps especially popular culture, remain fascinated with depictions of mental health/illness.
Imogen Wiltshire puts the visual and tactile arts at the center of her study, set in the first half of the twentieth century (chapter 10). She concentrates on the way positive images of mental health were represented and promoted alongside the use of art to capture highly subjective illness experiences and as therapy for patients. Wiltshire usefully highlights the important point that, by the 1960s, art tended to “romanticize” mental illness while taking an increasingly critical view of asylums and treatments. With respect to the era of deinstitutionalization, Wiltshire associates the loss of asylums with a move toward more drab and utilitarian art projects, although the idea of creativity and artistic endeavor, certainly at the level of everyone who can do craft projects, as a strategy for maintaining emotional well-being was an oft-repeated message during the 2020 Covid-19 lockdown.
This year has been a time when the public has been, and has been made, very conscious of mental health issues and threats to their mental well-being. The media has certainly fed public fascination with this topic in ways that seem likely to both assist and undermine strategies to promote personal mental well-being, encourage appropriate engagement with mental health services, and reduce the stigma attached to seriously ill or disabled service-users. While written long before the pandemic, Healthy Minds feels very relevant in the strange conditions we are being urged to accept as the new normal. Mental health has never felt so fragile, but we know that existing and new patients have struggled to access specialist services during the emergency. Several tragedies have been reported but those reports have struggled to make much impression amid all the other bad news—no great reform program seems imminent.
One of the strengths of Healthy Minds is its interest in space and the idea of contested spaces where battles could be fought, won, and also retreated from. When I first started researching mental health and learning disability topics in the late 1990s, the historiography was still wedded to concepts of medical imperialism and state power. Yet the history of the recent past shows only too clearly the limits of both. Health Minds offers an interesting commentary on some of the issues raised. In a very positive sense, new thinking has allowed and encouraged the de-medicalization and decriminalization of homosexuality. However, in the era after deinstitutionalization many seriously mentally ill people and their families must have felt abandoned rather than liberated. With adult social care now dominated by the needs of the mentally frail elderly, I think the Healthy Minds project needs expanding to encompass these concerns, and to perhaps offer more commentary on resource pressures than is included in many of the chapters.
This is the first completely open-access book that I have had the opportunity to review, and the format appears to raise some technical questions. Open access is, in many ways, beneficial, and the high-quality case studies developed in Healthy Minds certainly deserve the widest possible audience. Hopefully, the new publishing model will facilitate the engagement of students, practitioners, and others who might otherwise be deterred by the high and rising cost of hardback publications. With access to research libraries currently problematic because of Covid-19, the online option makes this type of publication a valuable resource for undergraduate teaching and learning as well as for independent study. However, as someone used to more traditional publishing models, this reader also has some concerns. The following remarks should, however, not be read as a criticism of the authors or editors involved in the creation of Healthy Minds because they are a comment on issues that they will personally have had little control over.
As a reviewer I think it is important to recognize the sheer hard work as well as intellectual endeavor that goes into producing any book. Therefore, commentary should normally be directed toward assessing the originality of the research, the quality of the analysis, the strength of any conclusions offered, and their applicability to wider studies in the field. It is usually completely inappropriate for a reader to highlight minor errors such as typos. However, the open-access nature of this publication introduces a sense of fluidity, a feeling of incompleteness, and the idea of a work still in progress. This impression is fostered by the list of corrections that appears on page C1, which also provides links to updated online versions of the original papers.
Strangely, despite this clear evidence of multiple drafts there are still a surprising number of errors. Most are confined to the endnotes, and while none of them are particularly serious they tend to suggest that the perceived benefits of publishing documents that can be changed and updated by their authors risks undermining the careful copyediting process that has underpinned the quality of more traditional outputs. It is, for example, hard to see how a date has been allowed to pass as “200.” In these cost-conscious times it is clear that authors and book editors will have to bear in mind the declining level of technical support that may be available from publishers. Technology is often proposed as a solution, but it is fallible and may inadvertently create as many problems as it solves. Predictive text is assumed to be the reason “A[ndrew] Knox” erroneously appears as “A. Know”!
These are fairly minor quibbles, but I think that there is a more serious issue that needs to be considered. Elsewhere in this review, I praised the coherence of the different contributions, the thoughtful collective critique of the existing historiography, and the book’s accessibility to students as well as scholars. The authors and editors have worked hard to draw out unifying themes and also reveal subtle points of difference. I read and enjoyed all the contributions and started to follow up the flagged links to other chapters and wider reading. However, my ability to do this was impaired by the very limited index. A few subjects, places, institutions, organizations, and contemporary actors are listed, but there are none of the historians I would have expected to see. It now seems less common for books to have a separate index for people, but the names of leading researchers whose work is referenced on multiple occasions could, and should, be included somewhere. At present, it feels like the open-access model has encouraged a focus on individual contributions at the expense of the work as a whole. While this may not be a problem with other open-access works, I do think that the effort that has gone into making Healthy Minds such a coherent set of essays deserves equal attention to presentational details. I nonetheless commend the volume and would encourage readers to take time to engage with all the chapters. Each has real merit, and collectively they add up to more than the sum of their parts.
Note
[1]. Peter Bartlett and David Wright, eds., Outside the Walls of the Asylum: A History of Care in the Community, 1750-2000 (London: Athlone Press, 1999).
If there is additional discussion of this review, you may access it through the network, at: https://networks.h-net.org/h-disability.
Citation:
Pamela L. Dale. Review of Taylor, Steven J.; Brumby, Alice, eds., Healthy Minds in the Twentieth Century: In and Beyond the Asylum.
H-Disability, H-Net Reviews.
October, 2020.
URL: http://www.h-net.org/reviews/showrev.php?id=55246
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